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Orbital fracture management
1. SEMINAR ON-
CLINICAL ASPECTS AND MANAGEMENT
OF ORBITAL FRACTURE
PRESENTED BY-
Dr. MRINALINI MATHUR
MODERATED BY-
Maj. Gen (Dr.) A.K. Nandi
(Professor)
Dr. Parul Tandon
(Reader)
4. CLINICAL PRESENTATION
BASED ON THE AREA INVOLVED
1- Periorbital Tissues:
Oedema
Subconjunctival Hemorrhage
Circumorbital Ecchymosis
Subcutaneous Emphysema
2- Eyelids:
Narrowing Of Palpebral Fissure
Ptosis
5. 3- Ligaments:
Antimongoloid Slant
Telecanthus
4- Eye:
Limitation Of Ocular Movements
Diplopia
Enophthalmos
Alteration Of Ocular Level
5- Lacrimal Apparatus:
Epiphora
6- Neurological Deficits:
Paraesthesia Along The Distribution Of Infraorbital Nerve
22. Normal orbital anatomy. Axial computed tomographic (CT) image (left) with color
overlays shows the orbit divided into intraocular and extraocular spaces by the
muscle cone and their relationships to the globe. Coronal CT images (right) with color
overlays show the configuration of the extraocular muscles, vascular structures, and
lacrimal gland.
23. TREATMENT PROCEDURES
There are 4 treatment options.
OBSERVATION
: for atleast
two weeks
CLOSED REDUCTION OPEN REDUCTION WITH
OR
WITHOUT INTERNAL FIXATION
ORBITAL RECONSTRUCTION
IMMEDIATE
: within 1-2
days
DELAYED
: within 2
weeks
IMMEDIATE
: within 1-2
days
DELAYED
: within 2
weeks
24. INDICATIONS
FOR OBSERVATION
1. Minimal diplopia
2. Good ocular motility
3. No significant enophthalmos
4. CT scan that shows a defect not likely to result in enophthalmos
5. Small defects
FOR SURGICAL REPAIR
1. Diplopia >7-10 days
2. Signs of muscle entrapment
3. Enophthalmos >2mm
4. Fracture of >50% of orbital floor
5. Muscle entrapment that causes an oculocardiac reflex with resultant bradycardia and cardiovascular
instability.
6. Progressive infra-orbital nerve numbness.
25. IMMEDIATE REPAIR
1. Non resolving oculocardiac reflex with muscle entrapment
2. Early enophthalmos
3. White eyed floor fracture with muscle entrapment
DELAYED REPAIR
Majority of orbital fractures are managed initially with observation, then surgical intervention is done if
required, within 14 days of injury.
1. Symptomatic diplopia with positive forced duction test
2. Large defects resulting in enophthalmos
3. Significant hypoglobus
4. Progressive infraorbital paraesthesia
26. OBSERVATION
Medical management of internal orbital fracture includes:
1- Periorbital Swelling
Steroids- 8mg dexamethasone initially followed by 4mg every 8 hours for 3 days post-op
Cold compress
Head propped at 30֯
2- Sinus Precautions
No blowing of nose as it could lead to periorbital emphysema
3- Blood Pressure
To be managed if it is high to prevent increased bleeding into orbital and periorbital compartments
4- Anticholinergics
Muscle entrapment causes bradycardia due to the oculocardiac reflex. Treatment includes the
administration of 0.01-0.015mg/kg atropine and 0.007mg/kg glycopyrrolate.
27. 5- Use of Broad Spectrum Antibiotics
6- Use of Nasal Decongestants
7- Maintenance of Ocular Pressure
Normal ocular pressure: 12-22mmHg
If the increase in intraocular pressure is < 30mmHg we carry out medical treatment, which
includes the administration of: steroids
acetazolamide
mannitol
topical timolol
If the increase in intraocular pressure is > 30mmHg we carry out surgical decompression, which
includes:
lateral canthotomy followed by inferior cantholysis
incision and drainage
28. CLOSED REDUCTION
Endoscopic Repair
Indications-
- Patients with trap door fracture of the floor
- Patients with blow out fracture of the medial wall
Advantages-
- No scars so greater patient acceptance.
- No ectropion
- Helps in immediate repair without the need to wait for edema to reside
- Magnified visualization
- Access through smaller incisions
- Less post-op morbidity
- Can be done under LA which makes intra-op evaluation of ocular movements and diplopia possible
30. Complications Of The Technique Are- Facial hyperesthesia Limitations- Used to repair just the orbital floor
Oroantral fistula
Dacryocystitis
Gingivobuccal wound dehiscence
Facial swelling
Numbness of teeth
Recurrent sinusitis
t
32. Advantages Of The Techniques Are-
- No scar.
- Direct access and management of
orbital floor fracture through space
anterior to nasolacrimal duct resulting
in easier operation with straight
endoscope and instruments.
- Less buccal discomfort.
- No fixation needed.
- Used to repair floor and medial wall
fractures.
33. SURGICAL APPROACHES
TO THE ORBITAL ROOF AND LATERAL ORBITAL WALL
1. Lateral Eyebrow Incision
2. Upper Eyelid/ Blepharoplasty Incision
3. Coronal Incision
4. Lateral Canthotomy Incision
5. Lateral Extension Of Subciliary Incision/Lower Blepharoplasty
39. Subperiosteal dissection of
lateral orbital rim and lateral
orbit
The periosteum is then
dissected from the lateral
and posterior surface of the
superolateral rim
Closure of periosteum
53. TO THE FLOOR OF THE ORBIT
1. Subciliary Approach/ Lower Blepharoplasty Incision
2. Subtarsal Approach/ Lower Or Mid eyelid Incision
3. Transconjunctival Approach/ Inferior Fornix Incision-
It’s of 2 types:
a.) Preseptal Incision
b.) Retroseptal Incision
61. WAYS TO PERFORM
TRANSCONJUNCTIVAL APPROACH
A. Transconjunctival(inferior fornix using either Preseptal or
Retroseptal route.
B. Transcaruncular( medial transconjunctival)
C. Lateral Canthotomy( transconjunctival with lateral skin
extension)
D. Combination of A+B
E. C-shaped combination of A+B+C
62. DISSECTION
OF THE ORBITAL ROOF
-The roof of the orbit is triangular in shape.
It has a distinct anterior concavity being
greatest about 1.5 cm posterior to the
supraorbital rim, which corresponds to the
equator of the globe.
-The orbital roof is thin and fragile except
for the posterior convergence, where it
consists of the lesser wing of the sphenoid.
-The roof can be significantly pneumatized
due to the extension of the frontal sinus and
the ethmoid air cells.
63. -Laterally, the lacrimal gland fossa is located medial to
the zygomatic process and enlarges the post rim
concavity.
-The trochlear fovea is a small depression
superomedially.
-Above the fossa the frontal sinus extends postero-
laterally commonly reaching the mid-point of the orbital
roof.
-Medially, the ethmoid air cells make up the orbital roof.
Here, the roof appears to have multiple pits (foveolae
ethmoidales) with bony ridges in between.
-The anterior and posterior ethmoidal foramina are
located along the frontoethmoidal suture line in the
transition zone from the roof to the medial wall of the
orbit.
64. -Fractures of the roof of the orbit are essentially anterior skull base fractures.
They are associated with frontal sinus fractures or fractures of the squamous
portion of the frontal bone.
-Exposure of the roof of the orbit is normally done via preexisting lacerations or
most often via a coronal approach. The roof is entered over the edge of the
supraorbital rim.
-The periosteum over the supraorbital rim is densely adherent to the bone and
great care is taken not to tear to prevent herniation of the contents of the
periorbita.
-Elevation of the periorbita begins superiotemporally from the frontozygomatic
suture line in the area of the periorbital sac where the periorbita is condensed and
more resistant to injury If the periorbita is violated, the lacrimal gland will
prolapse into the surgical field.
-The elevation is then continued medially, to detach the periorbita along the entire
supraorbital rim. The supraorbital neurovascular bundle must be released from its
notch or canal to allow the dissection of the medial orbital roof to proceed.
65. -The dissection behind the supraorbital rim must take into account the post rim concavity. The periosteal
elevators must be directed superiorly maintaining contact with the bone of the orbital roof to remain in a
subperiosteal plane and avoid injury to the contents of the periorbita.
-The frontal nerve and its terminal branches (supraorbital and supratrochlear nerve) is embedded within the
periorbita along the whole roof. Posteromedially the trochlear nerve lies in direct contact with the periorbita.
Both nerves can serve as a landmark in the dissection.
66. -Deep dissection of the periorbita along the roof of the orbit will lead to the posterior end of the bony
triangle, where the periorbital sac spans the optic foramen and the upper medial outline of the superior
orbital fissure.
-Another suspension arises from around the recurrent meningeal artery foramen, which is located more
anterolaterally.
The recurrent meningeal artery will be encountered when the periorbital dissection follows the
zygomaticofrontal and the sphenofrontal suture line, which both make up the lateral border of the orbital
roof.
Limit Of Dissection:
Till the periorbita surrounding
recurrent meningeal artery
67. OF THE LATERAL ORBITAL WALL
-A complete exposure of the lateral wall in its
boundaries from the lateral aspect of the
inferior and superior orbital fissure over the
greater wing of the sphenoid, the recurrent
meningeal foramen and the
zygomaticofrontal suture to the lateral orbital
rim can easily be achieved from a
superolateral access via a coronal approach.
-Using the coronal approach the periorbita is
raised with a periosteal elevator in the
inferolateral direction after the periosteum at
the orbital rims has been vertically incised
and reflected.
68. -During the periorbital dissection of the inferior portion of the lateral orbital wall two branches of the sensory
zygomatic nerve (branch of V2); the zygomaticotemporal and zygomaticofacial nerve are identified. They
pierce the periorbital sac, traverse the opened subperiosteal space and exit the orbit laterally.
-The periorbital dissection of the lateral orbital wall either from a superior or inferior access usually requires
division of these two sensory branches of the zygomatic nerve, causing loss of sensation to the skin over their
distribution in the area of the lateral orbital margin and the prominence of the zygomatic body.
69. -When necessary the periorbital
dissection proceeds posteriorly to the
temporal side of the orbital apex, until
the periorbital/dural soft-tissue reflection
at the lateral aspect of the superior
orbital fissure is identified.
-The recurrent meningeal artery passing
through the periorbita to its respective
foramen along the sphenofrontal suture
line is encountered during the deep
dissection.
-Inferiorly the lateral border of the
inferior orbital fissure will come into
view.
Limit Of Dissection:
Till superior orbital fissure
70. OF THE MEDIAL ORBITAL WALL
-Using a transcaruncular incision, the periorbita is incised
posterior to the insertion of Horner’s muscle along the posterior
lacrimal crest.
- The incision is made in a vertical direction either with a scalpel
or with spreading motions of a sharp pointed scissors. The
dissection is continued posteriorly underneath the periorbita
using a periosteal elevator.
-The path of dissection along the medial orbital wall starts
inferiorly and turns superiorly to create a subperiosteal cavity for
the insertion of a malleable ribbon retractor.
-The anterior ethmoidal neurovascular bundle is the first
transverse structure encountered at the upper limit of the
operative field.
-The periorbital dissection is continued posteriorly along this
suture line until the posterior ethmoidal neuro-vascular bundle is
exposed.
71. -The medial wall runs straight from anterior to posterior.
-Three important structures are encountered as we go posteriorly
from the medial orbital rim.
(a) Lacrimal fossa
(b) Anterior ethmoidal foramen
(c) Posterior ethmoidal foramen
-Anterior ethmoidal foramen is located on Fronto-ethmoidal(FE)
suture, 24mm posterior to the medial orbital rim. Through it
anterior ethmoidal vessels passes. If it is lacerated it can cause
bleed into the periorbita. So we cauterize it during dissection.
-During dissection of medial wall it is important to know that the
FE suture is at the same level as the cribriform plate.
-If one accidently pokes through the thin frontal bone just above
the FE suture line one can enter the anterior cranial fossa.
-As we go posteriorly we get the posterior ethmoidal vessels. It is
7-10mm from the optic foramen. So care must be taken as we go
posteriorly. Mostly the posterior ethmoidal vessels need not to be
cauterized because the fracture usually ends just short of it.
72. -The inferior border of the medial orbital wall is
defined by the ethmoid-maxillary suture line.
The bony condensation along this line is made
up essentially by the maxilla and represents an
internal orbital buttress, which often remains
intact in orbital trauma.
-The internal orbital buttress is further
supported by the basal lamellae framework (i.e.
basal lamellae of the ethmoid bulla and the
middle turbinate) and its honeycomb extensions
inside the ethmoid.
-The inferior limit of the periorbital dissection
along the medial wall goes beyond this
boundary and continues onto the posterior
medial bulge.
Internal orbital buttress/
Limit Of Dissection:
Till the posterior ethmoid foramen
73. OF THE FLOOR OF THE ORBIT
-Anatomy for reconstruction of floor is inferior
orbital fissure, groove, canal and nerve.
-Near the fissure the periosteum lining the floor
and lateral wall of the orbit invaginates into the
inferior orbital fissure. And this limits the extent
of exposure. So for adequate dissection for
exposure of the orbital floor we cauterize any
vessel that traverses the inferior orbital fissure
and we re-route the infraorbital nerve.
-As we go from anterior to posterior the orbital
floor ascends up at 30֯. If we do not ascend up as
we go posteriorly while dissecting we can end
up dissecting into the maxillary sinus.
74. -The best way to expose the defect completely is to
elevate the periosteum from the sound bone around
the defect. But many times the periosteum around
the defect is fragmented so the only structure along
the floor to help guide the path of dissection is the
infraorbital nerve.
-Remove the periorbital fat lying above the nerve to
expose the nerve and then follow the nerve
posteriorly to the point where it meets the posterior
aspect of the infraorbital fissure. There we locate
the posterior ledge of bone on which the
reconstruction material can rest.
-Once the defect is completely exposed and the
sound bone has been reached we place a piece of
radiographic film or any other similar sheet like
material that is a bit larger than the defect so that
edges of the film or foil rests on sound bone.
This helps confine the orbital fat so that a suitable
retractor can be used to visualize the defect.
75. -In the anterior just behind the rim the
floor is concave whereas posteriorly near
the transition zone it is convex. This is
called the lazy ‘S’ shape of the orbital
floor. This convexity or the upward bulge
of the maxillary sinus is important to
reconstruct because it helps maintain the
anterior position of the globe.
Limit Of Dissection:
Till the posterior ledge of bone
76. Key Areas To Keep In Mind
During Orbital Reconstruction
Posterior Ledge
Lazy “S” of the orbital floor
Posteromedial
Bulge
Transition
Zone
77. RETRACTION
Special malleable orbital retractors
(straight or anatomically formed) are
available with metric markings
providing the surgeon with additional
information regarding the extent of
the fracture and the depth of the
orbital dissection. Specific orbital
retractors have been developed to
improve orbital retraction and
minimize prolapse of soft tissue
during insertion of implants.
78. Foil greater than the size of the retractor is
selected.
Insertion of this foil
below the retractor.
The retractor is then removed, placed
under the foil, and the orbital soft
tissues are properly retracted.
Proper retraction involves the following steps:
Appropriate
retraction of the
intraorbital soft
tissues has to be
performed.
79. OPEN REDUCTION
OPEN REDUCTION WITHOUT
FIXATION:
In some cases the orbital floor
may be reduced and the fracture
segment may be stable. Fixation
may not be needed.
OPEN REDUCTION WITH FIXATION:
In some cases the orbital floor may be
reduced but the fragment is not stable.
In such cases a small bone plate can be
secured to the stable bone laterally
within the orbit and the medial
extension is placed underneath the
reduced trap door.
80. RECONSTRUCTION MATERIALS
AUTOGRAFTS
1- BONE GRAFT
Most commonly used are calvarial bone graft and iliac crest graft.
Indications: Fractures in children <7years of age.
Advantages: Biocompatibility Disadvantages: Donor site
Radiopacity Contour change
Variability in thickness Difficult to shape
Good strength Bone resorption
81. 2- CARTILAGE
Mostly septal and auricular cartilage are used.
Indications: Small fractures
Advantages: Biocompatibility Disadvantages: Poor structural support
Minimal donor site morbidity Not radio-opaque
No sharp edges
82. 3- TITANIUM MESH
Indications: Large orbital defects
Advantages: Stability Disadvantages: High cost
Biocompatibility Sharp edges
Ease in contouring Chances of tissue ingrowths
Radiopacity
Spaces within the mesh allow drainage of fluids
No donor site is needed
83. 4- POROUS POLYETHYLENE SHEETS(PPE)
Indications: Defects with sound edges to support the implant
Advantages: Availability Disadvantages: Not radio-opaque
Easy contouring Lacks rigidity
Smooth edges Less drainage from orbit than with titanium mesh
Biocompatible
Good strength
84. 5- PPE+TITANIUM MESH
Advantages: Availability Disadvantages: Less drainage as compared to the mesh alone
Stability
Ease of contouring
Radiopacity
Rigidity
No donor site needed
85. 6- RESORBABLE SHEETS
Made up of polylactide, polyglactin and polydioxanone.
Of two types- thermoplastic and non-thermoplastic.
Indications: Small gaps < 2.5cmx2.5cm with stable medial and lateral borders (mostly in children)
Advantages: Biocompatible Disadvantages: Cost
Pliable and can be contoured Doubt on long term stability and support
Resorbable Not radio-opaque
Infection/ inflammatory response
86. PRINCIPLES OF RECONSTRUCTION
1. When the defect is LARGE-
THIN, RIGID MATERIAL which maintains the shape forever.
2. Use MINIMUM SIZE NECESSARY-
The material should span the entire defect and its edges should lie on sound bone.
3. Proper SHAPING of the material prior to insertion-
This is done to properly recreate the normal anatomy of the internal orbit.
4. TENSION FREE placement of the implant-
The best way to assess it is to repeatedly do the forced duction test.
Perform FDT – as soon as the patient is anesthetized
as soon as the orbital dissection has been performed
after reconstruction material has been placed
87. 5- STABILIZE the material-
Implant if mobilized can cause infection and inflammation.
Stabilization of the implant is done by securing it with a screw to the adjacent orbital wall, rim or other
location.
6- ADEQUACY of reconstruction should be VERIFIED-
The best way to do this by verifying the shape and volume of the orbit using intra-op CT Scan.
88. POST-OPERATIVE CARE
1- Ophthalmological Examination:
It includes: Vision
Extraocular motion
Diplopia
Globe position
Lid position
If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.
2- Patient should be positioned with head elevated.
3- No blowing of nose.
4- Medications:
Includes: Steroids
Antibiotics
Analgesics
Nasal decongestants
5- Wound care
6- Regular post-op radiographs
89. COMPLICATIONS
Intra-operative Complications:
- Globe and optic nerve injury
- Injury to the infraorbital nerve
- Inadequate reduction of prolapsed tissue
- Oculocardiac reflex
- Hemorrhage
Post-operative Complications:
- Blindness
- Persistent diplopia
- Globe malpositioning: exophthalmos and enophthalmos
- Lid malpositioning: ectropion and entropion
- Infraorbital nerve dysfunction
- Infection
- Retrobulbar haemorrhage
- Implant infection, migration or extrusion
- Epistaxis or CSF leakage in medial wall repairs
90. RETROBULBAR HEMORRHAGE
Orbital CT scan, axial view showing a well-
defined intraconal mass in the left orbit that
pushed the optic nerve medially.
91.
92. WHITE EYED BLOW-OUT
FRACTURE
A, External photograph of white-eyed blowout fracture in right eye. B, Elevation limitation of the right eye at
presentation. C, Computed tomograph (sagittal section) showing fracture of orbital floor with inferior rectus
entrapment. D, Postoperative resolution of motility restriction.
99. REFERENCES
- ROWE AND WILLIAM’S maxillofacial injuries.
- FONSECA oral and maxillofacial trauma 4th edition.
- PETERSON’S principles of oral and maxillofacial surgery 3rd edition.
- RAJIV M. BORLE textbook of oral and maxillofacial surgery.
